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Clinical Cardiology

Introduction

The Ohio State University College of Veterinary Medicine has offered clinical residency training in Cardiology since 1975 (http://vet.osu.edu/education/clinical-cardiology). The program is ACVIM-approved and supervised by three faculty members of the Cardiology & Interventional Medicine Service.

The residency is three years in duration and integrated with the Graduate-Residency Program of the Department of Veterinary Clinical Sciences with the major focus on specific coursework and seminars relevant to quality training in clinical cardiology. The program provides the trainee with focused clinical training in the specialty of veterinary cardiology and a clinically-oriented graduate education leading to the Master’s degree in Veterinary Clinical Sciences (see below). The training program is designed to prepare the resident for a career in either clinical academic medicine or in specialty cardiology practice. The faculty mentors are interested in attracting outstanding resident candidates and do recognize that most applicants are still considering career options at the time of their application. The graduate curriculum has been developed with courses specifically tailored for cardiology residents; these are highly relevant to clinical training and board certification and delivered within the Veterinary Medical Center during our normally-scheduled resident training periods (early AM, weekdays). The curriculum includes graduate courses in comparative electrocardiography and cardiac pacing, echocardiography, congenital heart disease, cardiac catheterization & angiography, and cardiovascular pharmacology. Additionally, there is a monthly cardiopathology conference, a weekly internal medicine case conference (CPC), and a weekly cardiology journal club (or cardiopathology conference). Cardiology residents will find themselves well-supported in the MS program and complete courses integral to quality training in the specialty. For those candidates focused on an academic research career, there is also a potential for advanced research training (PhD or Fellowship) in the College of Veterinary Medicine’s Graduate Programs immediately following completion of the residency. As with most academic residency programs, a research project is required and this is integrated in the MS program in the form of a clinical study and submission for journal publication. Each resident has a specific, dedicated research advisor as well as a research committee to support the resident as they complete their clinical research project.

Objectives

The main programmatic outcomes of the residency include successful completion of the ACVIM certifying examination in Cardiology along with completion of departmental requirements in graduate education with a focus in cardiovascular medicine. Since 1975, 100% of residents trained in the program have been successful in obtaining board certification and fulfilling their graduate studies. These goals are met by combining an outstanding trainee with a well-structured program that spans three years. Specific objectives are focused on the resident developing:

  1. An understanding of the basis and mechanisms underlying cardiovascular (CV) diseases
  2. Expertise in the diagnosis and management of CV diseases affecting domesticated animals
  3. Competency in performing and interpreting noninvasive and invasive diagnostic studies of the heart and circulation
  4. Competency in performing catheter-based interventional CV procedures including interventional catheterization and pacing
  5. Experience in managing small animal patients with noncardiac thoracic diseases
  6. Clinical and didactic teaching skills
  7. Basic clinical research skills with contribution to the veterinary literature

Faculty and Staff

Faculty members directly involved in support of the program currently includes three board-certified cardiologists, Dr. John Bonagura (Program Director), Dr. Karsten Schober (Professor and Head of Clinical Service), and Dr. Jaylyn Rhinehart (Assistant Professor). The program is long-standing with extensive experience in training residents. Dr. Robert Hamlin (DACVIM-Cardiology) supports cardiovascular education and research and is available for consultation.  There are two cardiology residents in training and there are two experienced technicians assigned to cardiology and Interventional Medicine.

Other faculty members on site include those with specialties in internal medicine (including those focused on gastroenterology, nephrology/urology, neurology, and oncology) ophthalmology, radiology/ultrasound/ nuclear medicine, general and orthopedic surgery, anesthesiology, dermatology, emergency and critical care medicine, behavior, and theriogenology.  Clinical pathologists and pathology residents support the hospital program. Anatomic pathologists and microbiologists are also on site to support clinical efforts and participate in a monthly cardiopathology conference. There is a good amount of daily interaction among services.

Prerequisites and Applications

Applicants must be graduates of a faculty-approved College or School of Veterinary Medicine with demonstrated academic proficiency (academic standing that as a minimum is within the top 50% of the professional graduating class is expected). Applicants must have completed a one-year rotating internship or equivalent experience (that is acceptable to the faculty). All residents must be eligible to obtain a limited (university) license to practice veterinary medicine in the State of Ohio.  At least three references are required. Due to recent changes in USA/University Visa policies, we unfortunately cannot accept residency applications from abroad at this time (contact the Departmental office for details).  

Beyond these minimal requirements, the Cardiology Faculty consider at least ten other factors before ranking applicants for our residency program. These include: 1) Academic record and class rank; 2) Potential for self-learning; 3) Clinical proficiency demonstrated during a high-quality internship or clinical training program; 4) Evidence of common sense and practicality; 5) Demonstrated ability to work cooperatively with others; 6) Professional and personal ethics and comportment; 7) Communication skills; 8) Desire to train within an academic veterinary center,  contributing to the instruction of professional students;  9) Interest in contributing to the clinical research program of the Cardiology & Interventional Medicine Service; and 10) Personal or professional experiences that further distinguish the applicant.

Cardiology residencies are highly competitive and very limited in number. Currently Ohio State takes two cardiology residents every three years in a staggered schedule.  The overall application process involves 1) standard application by candidates through the VIRMP “Match” system; 2) review of applications by the faculty (including contacting of references); and 3) inviting candidates for interview. Candidates wanting an early decision regarding an interview, are urged to submit credentials to VIRMP by late November of the year preceding the residency start date. The VIRMP Match program does not provide a very large time window between application and rankings, and we do try to review applications immediately so we can invite candidates as soon possible for our interview date which is held in January every year (the precise date is indicated on the VIRMP “match” description of program).

We do require a personal interview for acceptance to our program. Candidates will be invited to interview based on our review of applications and calling of references. We generally invite 5 to 10 candidates who we believe have the best chance of matching with our program. Our interview day is structured so that each candidate will hear “general information” as part of a group of candidates, receive a tour of facilities, and then meet individually (one-on-one) with each cardiologist (both faculty and residents) as well as our veterinary technicians. There is also an informal lunch Q&A period. Interviews begin at 8 AM and conclude between 4 and 5 PM (for one calendar day). For those coming for interviews, we will advance additional information regarding travel and lodging suggestions for Columbus, Ohio (airport code CMH). An agenda of the interview day, along with your specific interview schedule, also will be provided prior to your on-campus visit. Again, the date for candidate interviews is set for January of the year the residency begins. Unfortunately, we do not schedule personal interviews outside of our interview date. (In exceptional situations we will conduct a SKYPE interview).

While applications are not due to VIRMP until December, applicants who are interested in attending our interview day should submit their applications to VIRMP as soon as possible. We accept that some letters of recommendation might not be submitted by that time, but your application, academic record (INCLUDING CLASS RANK, not just GPA), letter of intent/cover letter should include the names of your references so we may contact them before the final application date if necessary. This will allow us to “preview” individual applications and to decide if an interview will be requested. We will endeavor to make interview decisions by early December. Each applicant will be notified about our review and whether or not an invitation will be extended.

Orientation 

During the first week of the residency program, all incoming residents participate in a comprehensive orientation program to introduce them to the department, college and university, complete necessary documentation, and to facilitate integration into our program and activities.  Once the resident starts on the cardiology clinical service there is constant faculty supervision of clinical activities rotated among the three clinical cardiologists. There is also a faculty backup schedule for off-hours and holiday emergencies/procedures. As might be expected, residents are gradually introduced to the medical, diagnostic, and interventional practices of the service at a rate appropriate with their experience and training.

Advisors and Mentoring

Each resident is assigned a primary ACVIM clinical advisor at the onset of the program and a primary research advisor (later, during the first year). The clinical research project is further supported by a committee of faculty members. Residents are provided with very strong faculty support for the success of their clinical training, board preparation, and clinical research project. It should be noted that all past OSU cardiology residents in our training program have successfully passed the ACVIM Certifying examination within the required 3-year period.

Clinical Program

The residency combines clinical training and rounds, weekly seminars and classes, self-study, and clinically-relevant research. The program is highly structured and organized to facilitate both clinical training and post-graduate education focused on cardiovascular medicine.  Specific goals are the development of strong competencies in physical and imaging diagnosis, echocardiography, electrodiagnostics (ECG, Ambulatory ECG), cardiac catheterization, angiocardiography, cardiac pacing, interventional cardiac procedures, with clinical competence in respiratory endoscopy.  Cardiology residents also are expected to develop at least core competency in general internal medicine and more advanced clinical skills in small animal respiratory disease diagnosis and management.

The program is 3-years in duration. The resident spends about 28 months in scheduled clinics within the Veterinary Medical Center over a 3-year period. Emergency service is shared throughout the residency with another cardiology resident (except during vacation). Six months (approximately 2 months each year) are designated as off-(primary) clinical service to allow for clinical research and board- preparation. Two weeks per year are allowed for personal leave/vacation. Residents attend the ACVIM Forums during their second and third years of the residency. Time off to attend other professional meetings is granted on a case-by-case basis.

Clinical experiences include primary care cardiology in a referral hospital; in-hospital case cardiology consultation in small and large animals; management of small animal patients with respiratory diseases; and consultation on patients with multi-systemic internal medicine disorders that involve the heart and circulation. The residents and cardiology faculty member on service work side-by-side as part of a service (with students and interns). The resident receives a structured performance evaluation yearly and informal feedback regularly. When the resident is on the cardiology clinical service, there is constant faculty supervision of clinical activities rotated among the cardiologists with a faculty backup schedule for off-hours and holiday emergencies/procedures.

The clinical service also carries an interventional medicine component (the official service name is “Cardiology & Interventional Medicine”). This includes cardiac pacing, cardiac catheterization, interventional cardiology, and catheter-based treatments for airway diseases, vascular disorders, and other medical procedures (although cardiology residents generally do not work outside of the cardiovascular and respiratory systems). Catheterization procedures are conducted in a new Catheterization Suite and Hybrid operating room within the Veterinary Medical Center. This Suite includes a GE C-Arm with full cardiovascular capabilities, integrated procedures table, and other equipment needed for catheter-based and hybrid surgical therapies. The Cardiology Clinic caseload is approximately 1500 to 1600 cases per year including in-house consultations. Of these approximately 90% are related to cardiovascular disease and about 10% are respiratory disease based. Large animal cardiovascular consultation is a small but regular part of the weekly caseload. The cardiovascular interventional caseload is about 75 cases per year. Additionally, there are recently-acquired advanced imaging modalities on site (new 128-slide CT scanner and 3T-MRI).

Clinical rotations for cardiology residents are centered in the Clinical Cardiology Service, except for two to four weeks on the Internal Medicine service and 1 week in Radiology & Diagnostic Imaging. The hospital has a dynamic environment. Daily interaction with colleagues in internal medicine, oncology, neurology, radiology, anesthesiology, critical care, emergency medicine, and surgery is typical. We also provide case consultation for these services along with support for the community practice, equine medicine & surgery, and the food-animal medicine & surgery services. The hospital is busy relative to many academic practices, and the hospital includes a full complement of clinical specialists. Residents do have limited emergency-care responsibilities; currently this involves backing up interns for cardiology patients. Backup responsibilities occur during both “on-clinics” and during some “off-clinic” periods. The cardiology residents split emergency backup duty so the experience and the workload are shared.

Clinical training is augmented with a series of weekly seminars, journal clubs, book clubs, and classes that constitute the didactic portion of the training program. Residents receive a formal education in mechanisms of disease, pathophysiology, pharmacology, and clinical sciences. All hospital residents at Ohio State participate in this program, which leads to a MS degree, and is described in more detail in the next section. These classroom experiences are designed to prepare the resident for general and specialty board examinations, and to foster the highest quality practice in the academic or private sector.  There are other opportunities for observation and education at the OSU Medical Center and Nationwide (Columbus) Children’s Hospital. Residents have access to extensive cardiovascular video, slide, and pathology libraries. Residents attend two ACVIM Forums (2nd and 3rd years) and can attend at least one human cardiology conference during their residency. 

The Typical Weekly Schedule is indicated below:

Monday – cardiology staff meeting/ cardiology research meeting/ departmental research conference; Clinics - receiving/workups/consults/ward rounds (9 AM until done).  

Tuesday – Medicine Clinical-Pathologic Conference (8 to 9 AM); Clinics receiving/workups/consults/ward rounds (9 AM until done)

Wednesday – Graduate-Resident courses (7 or 8 to 9 AM) followed by Teaching rounds; Special procedures – catheterizations, elective pacemakers, interventional procedures (AM); Clinic cases & consults (afternoon)

Thursday – Graduate-Resident course (7 to 9 AM) followed by Clinics receiving/workups/consults/ward rounds (9AM until done)

Friday – Cardiology journal club or path conference (2nd Friday of month is path conf; 8 to 9 AM); Clinics receiving/workups/consults/ward rounds (9 AM until done).

Daily consults include occasional horses, cattle, and camelids as well as dogs, cats, and other species. Although we schedule elective catheterizations, emergent procedures including pacemakers are performed as needed.

Evenings/Weekends – backup for emergency cardiology cases (interns have primary duty)

Graduate Program & Research Programs

The development of clinical expertise is prized and fostered. Additionally, as an academic institution, the faculty place both teaching and clinical research as fundamental to the efforts of the Cardiology Service, including our cardiologists in training. We expect our residents to actively participate in the clinical academic program, working alongside faculty members, and to teach a small number of elective classes and teaching laboratories to third-year students. Additionally, a portion of the training program is devoted to graduate education and clinical research. Although some candidates might have doubts about the relevancy of the MS program, the faculty in Cardiology have developed a course curriculum that is highly relevant to clinical education and board preparation, and the Department has a well-established combined Residency-Graduate program. While a graduate program is not part of the residency program at most institutions, it has been a long-standing and well-integrated part of the OSU residency program. Sufficient time is allowed off clinics for completion of the research project. All of our past cardiology residents have successfully completed the requirements for both specialty board certification and credits for the M.S. degree within the stipulated period of training. Cardiology residents can complete all of their needed coursework within the Veterinary College Campus, with all classes delivered within a scheduled, 3-year course cycle. Nearly all the classes are taught by the cardiology faculty for the cardiology residents. Classes are taught prior to routine clinical duties and this time off is fully supported by the faculty. The current schedule of graduate activities includes the Clinical Pathologic Conference seminar every Tuesday at 8 AM; one or two graduate classes taught on Weds at 8 AM and Thursday from 7 to 9 AM; and Cardiology Journal Club Friday 8 AM. These courses are each taught within the hospital building, prior to the start of clinics. Classes in Veterinary Clinical Sciences are focused on clinical subjects. Residents must complete semester 20 semester hours of official graded coursework over three years along with additional ungraded credit for seminar and for performing their research project. The current curriculum for cardiology residents includes the following course subjects comprising 13 of these 20 semester hours: Electrocardiography/Arrhythmias/Electrophysiology/Pacing (3h); Electrocardiography reading conference (2h); Echocardiography (2h); Cardiac Catheterization, Angiography & Intervention (2h); Congenital Heart Disease (2h); and Respiratory Medicine (2h). The additional three credits can be obtained from the research methods courses required of all residents as well as special courses taught by the cardiologists on clinical topics. The courses in research methods and data analyses are especially relevant to residents who are completing a clinical research project and learning to critically read the clinical literature.

Residents work alongside faculty mentors when conducting their clinical research. The research interests of the faculty are varied, but are focused on spontaneous cardiovascular diseases of animals in the general areas of cardiomyopathy, echocardiography, cardiovascular pharmacology, and congenital heart disease. There are good cardiology research laboratory facilities in the hospital, including a dedicated research echocardiography system (integrated to the clinical system). Facilities for cardiac catheterization are also available for research. There is sufficient technical support (two technicians) to assist the trainee in clinical and laboratory studies, and the faculty research mentor plays an active role in the planning, implementation, and analysis of the resident’s project.  Graduate students are expected to complete their coursework and research in a diligent manner, and to conduct and complete their research on a scheduled basis. We expect the resident to submit at least one scientific manuscript for publication by the conclusion of the residency.

Evaluations

The resident receives a structured performance evaluation from all faculty members twice each year (December and June). Progress is discussed and constructive criticism advanced with the intent of helping the resident reach her or his potential as a cardiologist. The program is evaluated yearly as part of the ACVIM residency review process. We have been in constant compliance.

Specialty College Requirements

Requirements for board certification are indicated in the General Information Guide (GIG) or related documents printed by the American College of Veterinary Internal Medicine (www. ACVIM.org) and should be consulted for details. Each resident has an individual program approved by ACVIM at the onset of the residency.

Board Certification

The requirements for board certification are also indicated in the ACVIM publications. As previously noted, our residents are supported to attend ACVIM in the second year to write the general examination and in their third year to write the certifying examination. The passing rate for the residents trained in the cardiology program at OSU is 100%.

Expectations

Expectations for residents are best outlined during the orientation and initial months of training and then readjusted during semi-annual performance evaluations. General expectations are outlined under objectives. Residents can expect dedicated and interested faculty who are focused on patient care, clinical education and training, and programmatic (academic) goals of the department.

Updated 10/24/16